Expert Moots Casemix, Public-Private Partnership To Relieve Overloaded Public Health Care System

The Private Healthcare Productivity Nexus finds 20% of resources in private hospitals are unutilised, while public hospitals are overburdened with patients.

KUALA LUMPUR, Sept 22 – A hospital expert has proposed casemix and public-private partnerships to tackle the excessive burden on Malaysia’s public health care system and underutilisation of private health care that is largely caused by prohibitive costs.

In a panel at the Health Policy Summit 2022 last month, Dr Jacob Thomas, chairman of the Private Healthcare Productivity Nexus under the Malaysia Productivity Corporation, highlighted that 49 per cent of patients who frequent public health facilities are willing to seek treatment at private facilities, if the cost is reasonable, and only about 15 per cent of patients are completely opposed to obtaining treatment at private facilities.

“The cost of private [health care] is expensive. Is it true? But it is actually a perception. There is a considerable gap in fees between the public and private health care facilities. There is a big gap because there are no subsidies for the private health care services,” said Dr Thomas in his address last August 15 at the Health Policy Summit organised by the Ministry of Health (MOH).

Therefore, to lighten the burden of the public health care sector, to maximise the utilisation of resources in the private health care sector, and to ensure that costs are not prohibitive, Dr Thomas proposed implementing a casemix system and a collaboration between the public and private sectors. 

Diagnostic Related Groupings or casemix is a system of classification that groups patients, their treatment, and associated costs. The goal of this casemix system is to establish a reasonable basic cost for both private and public hospitals and to ensure that patients receive timely reimbursements of the cost of treatment.

Utilising casemix will also allow for the sharing of doctors and specialists between the public and private sector, facilitate the deployment of patients from cancer centres from public to private facilities, and limit the need for patient transfer from public to private. 

This will not only help patients by reducing waiting times and costs, but it will also free up space in public hospitals which have fewer doctors, staff and equipment but more patients. Thus, this sharing of resources will be extremely beneficial for both sectors, as currently 20 per cent of resources in private hospitals remain unutilised, Dr Thomas said. 

According to Dr Thomas, the casemix system is currently “practised in a limited manner in some of our public hospitals and universities. And someone is helping the Nexus now to try and develop this on a trial basis in some of our hospitals – with the cooperation of the Ministry of Health. We don’t want two systems.”

This system, though relatively new to Malaysia, has been practised in other countries such as Japan, which uses the system to manage the long-term nursing care of the elderly.

In addition to the casemix system, Dr Thomas also highlighted the need for a Health Facility Briefing System (HFBS), like in the United Arab Emirates, Australia, and Oman. 

An HFBS is a centralised national platform for all public and private health care that is used to assist the government and the private sector in planning the future of health care facilities and systems with a next-generation supply and demand-modelling solution. 

Taking Australia as an example, it can be seen that their system comprises an integrated web of applications that covers information capture, project construction, design components, and service planning, amongst other things, to aid in efficiently managing their hospitals, staff, and patients. 

Such a system, according to Dr Thomas, will greatly improve efficiency and reduce the cost required to maintain the health care sector.

“We’ve seen this in other countries…where the entire system of having your health care details is in a computerised system. Details of each hospital, the licensing of hospitals is computerised, and all you need to do is tick off the boxes, and you’ll have your licence ready if everything is okay. 

“Similarly for new hospitals, it cuts down the cost of coming regularly for inspection by [MOH’s] CKAPS (Private Medical Practice Control Section) and other people. And we can even maintain the number of people working in each of them,” said Dr Thomas.

Invest In Building Primary Care Teams

While such methods are effective for hospitals in the tertiary sector, the continuous influx of patients is something that still has yet to receive a remedy, said Dr Mohammad Husni Jamal, president of WONCA Asia Pacific region.

In his presentation on reimagining primary care, Dr Husni suggested that following a shift in emphasis from curative care to preventive care, MOH should invest in building primary care teams.

Primary care teams are teams that comprise a multidisciplinary group of health and social care professionals who work together to deliver local accessible health and social services to a defined population of between 7,000 and 10,000 people at the “primary” or first point of contact with the health service.

Dr Husni stated that these teams are divided into two categories: the core group which comprises family physicians, nurses and community health workers; and an expanded team of public health experts, pharmacists and others, “depending on the needs of the patients and the families and the capacities of the communities.”

This model of health care not only allows doctors and other care professionals to reach rural communities, but also allows for patients to receive care at home, giving rise to a patient-centric medical home model of care, the second model of care that Dr Husni championed.  

“The patient-centred home – this is not really a physical structure, but it is actually representing a model of care, in which patients are in direct relationship with the chosen primary health care team,” Dr Husni told the Health Policy Summit. 

“And this PCMH (patient-centred medical home) has five functions and attributes – comprehensive care, it provides patient-centred care, coordinated care, accessible services and finally, it ensures quality and safety.” 

This, combined with good technical support and “a very good IT system and digital platforms”, will alleviate the burden placed on the tertiary care system and allow doctors and specialists in hospitals to focus on providing patients facing complex conditions with quick and appropriate treatment.  

That being said, Dr Husni stressed that the above systems of primary care are dependent on a good system of communication. In the question-and-answer session of the panel, he made it clear that a referral system that provides general practitioners (GPs) with feedback so that they may continue with treatment is crucial in ensuring patients receive effective and appropriate care.

“We actually relieve the burden of specialists in the hospitals, but you need a very good referral system. You need to have a proper system where referrals can be referred back.

“At the moment, what is needed for good communication is a proper referral system. Most of the time, and you can ask any GPs, when they refer [patients] to hospitals, they don’t get any feedback, so they don’t know what to do. So, to have good coordination with this new model — which has been proven — I think you have to work on a proper SOP (standard operating procedure),” clarified Dr Husni. 

The crystallisation of Dr Husni’s concerns and solutions can be found in India. In a study published in 2018 in the Journal of Family Medicine and Primary Care, researchers assessed the use of primary health care teams in India to alleviate the overburdened tertiary health care public facilities. This overburdening of facilities, according to the study, was a result of a “weak primary care system and absence of referral system”.

By the end of the study, it was concluded that the incorporation of primary health care teams in India resulted in the “widespread acknowledgement that these clinics have improved access to health services by qualified providers, to the poorest of the poor.”

Dr Hanafiah Harunarashid, pro vice chancellor at Universiti Kebangsaan Malaysia’s (UKM) Kuala Lumpur campus, said Malaysia should not focus on increasing the number of bigger hospitals, but to improve people’s health so that the nation only needs smaller and fewer hospitals.

“There is a myth that building more hospitals, building bigger hospitals means better, but actually it means that we have more sick people, and we should be looking after a healthier nation. And if the nations are healthier, therefore we should not have to need to build so many hospitals, or bigger, bigger hospitals in the future,” said Dr Hanafiah, in his video address.

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